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PTSD:


VA/DoD CLINICAL PRACTICE GUIDELINE
FOR MANAGEMENT OF POST-TRAUMATIC STRESS

A continuing education course for 12 ces

consisting of reading and taking a post-test on:

VA/DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF POST-TRAUMATIC STRESS

 


APA, BRN, CA BBS, FL, NAADAC, NBCC, TX SBEPC, TXBSWE
Who Should Attend


 

Establishing Therapeutic Alliance
Many people with PTSD find that their relationships with others have changed as a result of exposure to trauma. They often report that they have difficulty trusting others, are suspicious of authority, dislike even minor annoyances, and generally want to be left alone. Since the clinician-patient relationship draws heavily on trust, respect, and openness, and since the relationship often has to be formed in a busy clinical or bureaucratic setting, the provider may find the PTSD patient to seem to be withholding, negativistic, or even hostile at the initial meeting. The patient may seem to have “an attitude,” or “Axis II” co-morbidity. As a result, many combat veterans feel misunderstood or misdiagnosed by otherwise competent professionals, and ultimately the patient suffers through feeling betrayed and misunderstood by the mental health professional. If a therapeutic relationship is to have any opportunity to develop, the treatment provider must adopt a stance of caring and concerned involvement that takes what the patient says at face value, doesn’t judge or label this type of behavior, and doesn’t withdraw into an “objective” “professional” role. In short, the clinician who can relate honestly and openly is more likely to have a patient who is willing to relate to him/her as a fellow human being and an effective partner in treatment.
A general understanding of what has happened to the veteran is critical in this process of developing a therapeutic relationship. Every provider working with combat veterans should be advised to read some basic material on the experience of combat and watch documentaries of the same. The provider must develop an understanding that wartime and military service involves some of the most intense human experiences and that those feelings of profound rage, fear, and grief can be an expected part of these experiences. These feelings will be present in the interview setting and must be met with respect and compassion. It is also helpful for the professional to be careful not to assume that they have any understanding of the military experience if they have not themselves served in the military and should not be afraid to ask questions when they don’t understand something about the military that the patient is referring to.
Family, religious organizations and community leaders can be helpful when dealing with an unfamiliar culture and/or religion. It may also be appropriate to consult a local cultural adviser. But particular attention should be paid to the individual’s own beliefs and values, and confidentiality always must be maintained when getting input from other sources. Patient’s beliefs should be seen in the context of their social, religious, and cultural environment, and if need be, a trusted member of the person’s faith or cultural group should be consulted.

RECOMMENDATIONS
Treatment Options:
1. Strongly recommend that patients who are diagnosed with PTSD should be offered one of the evidence-based trauma-focused psychotherapeutic interventions that include components of exposure and/or cognitive restructuring; or stress inoculation training. [A]
The choice of a specific approach should be based on the severity of the symptoms, clinician expertise in one or more of these treatment methods and patient preference, and may include an exposure-based therapy (e.g., Prolonged Exposure), a cognitive-based therapy (e.g., Cognitive Processing Therapy), Stress management therapy (e.g., SIT) or Eye Movement Desensitization and Reprocessing (EMDR).
2. Relaxation techniques should be considered as a component of treatment approaches for ASD or PTSD in alleviating symptoms associated with physiological hyper-reactivity. [C]
3. Imagery Rehearsal Therapy [IRT] can be considered for treatment of nightmares and sleep disruption. [C]
4. Brief Psychodynamic Therapy can be considered for patients with PTSD. [C]
5. Hypnotic Techniques can be considered, especially for symptoms associated with PTSD, such as pain, anxiety, dissociation, and nightmares, for which hypnosis has been successfully used. [C]
6. There is insufficient evidence to recommend for or against Dialectical Behavioral Therapy (DBT) as first-line treatment for PTSD [I]
• Dialectical Behavioral Therapy can be considered for patients with a borderline personality disorder typified by parasuicidal behaviors. [B]
7. There is insufficient evidence to recommend for or against Family or Couples Therapy as first-line treatment for PTSD; Family or Couples therapy may be considered in managing PTSD-related family disruption or conflict, increasing support, or improving communication. [I]
8. Group Therapy may be considered for treatment of PTSD [C]
• There is insufficient evidence to favor any particular type of group therapy over other types
• Patients being considered for group therapy should exhibit acceptance for the rationale for trauma work, and willingness to self-disclose in a group.
9. Consider augmenting with other effective evidence-based interventions for patients who do not respond to a single approach.
10.Supportive psychotherapy is not considered to be effective for the treatment of PTSD. However, multiple studies have shown that supportive interventions are significantly more helpful than no treatment, and they may be helpful in preventing relapse in patients who have reasonable control over their symptoms and are not in severe and acute distress.
Note:
Approaches may also be beneficial as parts of an effectively integrated approach. Most experienced therapists integrate diverse therapies, which are not mutually exclusive, in a fashion that is designed to be especially beneficial to a given patient.


 

TABLE OF CONTENTS

INTRODUCTION 4
Guideline Update Working Group 11
ALGORITHMS AND ANNOTATIONS
CORE Module: Post-Traumatic Stress, Screening 15
Module A: Management of Acute Stress Reaction and Prevention of PTSD 30
Module B: Management of Post-Traumatic Stress Disorder (PTSD) 57
TREATMENT INTERVENTIONS
Module I: Treatment Interventions for Post-Traumatic Stress 102
I1 – Early Interventions to Prevent PTSD
I2 – Treatment of PTSD
I3 – Management of Specific Symptoms
APPENDICES
Appendix A. Guideline Development Process 199
Appendix B. Acronym List 206
Appendix C. PTSD Screening Tools 209
Appendix D. Participant List 213
Appendix E. Bibliography 222


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The Texas Board of Social Work Examiners (#6246)

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In this 12 unit course, Learning Objectives

The Clinician will be able to:

1. Triage and manage acute traumatic stress
2. Provide routine primary care screening for trauma and related symptoms
3. Evaluate diagnosis of trauma syndromes and co-morbidities
4. Evaluate evidence-based management of trauma-related symptoms and functioning
5. Outline psychological care in ongoing military operations
6. Evaluate proactive strategies to promote resilience and prevent trauma-related stress disorders


 

 

Assess Pre-Existing Psychiatric and Medical Conditions
OBJECTIVE
Identify patients at risk for complications.
BACKGROUND
Circumstances brought about by a traumatic event may complicate any existing psychiatric conditions or may exacerbate pre-existing pathology.
RECOMMENDATIONS
1. Assess patients for pre-existing psychiatric conditions to identify high-risk individuals and groups.
2. Assure access and adherence to medications that the patient is currently taking.
3. Refer patients with pre-existing psychiatric conditions to mental health specialty when indicated or emergency hospitalization if needed.
DISCUSSION
The NIMH (2002) guideline addresses the need to manage pre-existing psychiatric and medical conditions. The authors point to the “special needs of those who have experienced enduring mental health problems, those who are disabled, and other high-risk groups who may be vulnerable and less able to cope with unfolding situations.” They also call for additional attention to be paid to members of these groups in the immediate post-trauma period. However, they also emphasize that “the presumption of clinically significant disorders in the early post-incident phase is inappropriate, except for individuals with preexisting conditions.”
H Assess Risk Factors for Developing ASD/PTSD
BACKGROUND
Not all trauma survivors develop permanent stress disorders. Early identification of those at-risk for negative outcomes following trauma can facilitate prevention, referral, and treatment. Screening for those at greatest risk should address past and current psychiatric and substance use problems and treatment, prior trauma exposure, pre-injury psychosocial stressors, and existing social support.
RECOMMENDATIONS
1. Trauma survivors who exhibit symptoms or functional impairment should be screened for the following risk factors for developing ASD/PTSD:
Pre-traumatic factors
1. Ongoing life stress
2. Lack of social support
3. Young age at time of trauma
4. Pre-existing psychiatric disorders, or substance misuse
5. History of traumatic events (e.g., MVA)
6. History of post-traumatic stress disorder (PTSD).
7. Other pre-traumatic factors, including: female gender, low socioeconomic status, lower level of education, lower level of intelligence, race (Hispanic, African-American, American Indian, and Pacific Islander), reported abuse in
childhood, report of other previous traumatization, report of other adverse childhood factors, family history of psychiatric disorders, and poor training or preparation for the traumatic event.
Peri-traumatic or trauma-related factors
1. Severe trauma
2. Physical injury to self or others
3. Type of trauma (combat, interpersonal traumas such as killing another person, torture, rape, or assault convey high risk of PTSD)
4. High perceived threat to life of self or others
5. Community (mass) trauma
6. Other peri-traumatic factors, including: history of peri-traumatic dissociation.
Post-traumatic factors
1. Ongoing life stress
2. Lack of positive social support
3. Bereavement or traumatic grief
4. Major loss of resources
5. Negative social support (shaming or blaming environment)
6. Poor coping skills
7. Other post-traumatic factors, including: children at home and a distressed spouse.

Risk Factors for ASD
When evaluating risk factors for ASD, the clinician should keep in mind that ASD is no longer diagnosed later than four weeks after a traumatic event. Thus, not enough time will have passed following the trauma for many post-trauma factors to have had their full impact on the course of symptoms.
Risk Factors for PTSD
When evaluating risk factors for developing PTSD, the clinician should keep in mind that PTSD is defined as occurring only after four weeks have elapsed following a traumatic event. PTSD symptoms, however, may not appear until a considerable time has passed, sometimes surfacing years later.

 

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VA/DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF POST-TRAUMATIC STRESS

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We do adhere to the American Psychological Association's Ethical Principles of Psychologists. Our courses are carefully screened by the Planning Committee to adhere to APA standards. We also require authors who compose Internet courses specifically for us follow APA ethical standards.

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Cost of the 12 unit course is $143

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